A breast-cancer diagnosis can make the surgical decision feel urgent and overwhelming. For many patients with ductal carcinoma in situ (DCIS), a noninvasive cancer contained within the milk ducts, or early-stage breast cancer, the choice is between breast-conserving surgery, usually called lumpectomy, and mastectomy. When both are medically appropriate, the “bigger” operation is not automatically the better cancer operation.
For patients who are appropriate candidates, lumpectomy followed by radiation and mastectomy provide equivalent long-term survival.
The operations differ in treatment of the breast itself, recovery, radiation needs, appearance, reconstruction choices, and the chance of cancer returning in the breast or nearby area, but choosing mastectomy does not generally improve survival simply because more breast tissue is removed.
What is a lumpectomy?
Lumpectomy removes the cancer or DCIS along with a rim of surrounding breast tissue while preserving most of the breast. The laboratory report on the removed tissue shows whether the outer edges, called margins, are clear. If cancer cells reach an edge, additional surgery may be necessary.
Radiation therapy is usually part of breast-conserving treatment after lumpectomy, although the exact radiation plan depends on age, the features of the cancer cells, cancer stage, and other factors.
What is a mastectomy?
Mastectomy removes most or all of the breast tissue. Depending on the cancer and reconstructive plan, skin-sparing or nipple-sparing approaches may be possible for selected patients. Reconstruction can be performed at the same operation, delayed until later, or not performed at all.
A mastectomy can reduce the risk of cancer returning in the treated breast or chest area compared with lumpectomy, but it does not reduce that risk to zero. Some patients still need radiation after mastectomy depending on tumor size, lymph-node involvement, margins, and other features.
When might mastectomy make more sense?
- The cancer or DCIS occupies a large area relative to the size of the breast.
- Disease is present in multiple areas that cannot be removed with an acceptable breast-conserving result.
- Clear margins cannot be obtained after reasonable attempts at breast-conserving surgery.
- Radiation is not medically safe or recommended, or the patient prefers to avoid breast-conserving treatment that requires radiation.
- An inherited cancer-risk condition or exceptionally high future breast-cancer risk changes the discussion.
- The patient makes an informed preference for mastectomy after understanding the cancer-treatment tradeoffs.
What about lymph nodes?
Breast surgery and lymph-node surgery are separate decisions. In many patients with invasive breast cancer, a sentinel lymph-node biopsy samples the first lymph nodes that drain the breast to see whether cancer has spread. The need for more extensive underarm lymph-node surgery depends on the specific clinical situation.
The decision is about more than survival
When both procedures are medically appropriate for cancer treatment, quality-of-life considerations matter. These include breast preservation, body image, reconstruction, recovery, radiation, future imaging, anxiety about recurrence, the possibility of additional surgery, work and caregiving responsibilities, and the patient’s own values.
The best decision is made after the tissue-test results, imaging, cancer stage, features of the cancer cells, genetic information when relevant, and the expected role of radiation and medicines that treat the whole body are all understood. For many patients, there is time to ask questions and obtain a second opinion before choosing an operation.
Facing a breast-surgery decision?
Dr. Zadeh evaluates benign and malignant breast conditions and can help clarify the surgical options within the context of the overall treatment plan.